By Victoria Cleary
Recent high-profile emergency incidents have increased our focus on preparing for multicasualty incidents (MCIs). Whether you’re responding to an overturned bus, a tornado, or a terrorist bombing with many injured victims, do you know where to start? Do you know how to begin the process of identifying the most seriously injured victims and prioritizing their transportation off-scene?
分类哲学
Creating order in the midst of chaos is not an easy task. First responders are overwhelmed with a multitude of conflicting priorities. You need a simple tool to easily and rapidly identify those victims most at risk of early death. Triage is the tool you use when you cannot provide timely care to all victims. Emergency care cannot proceed until you locate, triage, and tag the victims for treatment and transport prioritization. Triage allows responders to do the most good for the greatest number of injured. It is the foundation of good medical management in the setting of a multicasualty incident.
The goal of triage is to rapidly identify the critically injured and prioritize their treatment and transportation. Triage is typically performed when the number of victims exceeds the ability of the rescuers to care for them in a routine manner.
What Can Go Wrong?
If you don’t have a good tool or system for triage, you can expect the following:
- Triage by emotion, which selects people based on who looks the worst. (Who is covered in blood or moaning the loudest?)
- 急救人员或EMT将使用他们每天通常使用的常规评估过程。这太耗时了。
- 受害者将长时间保持现场。
- 重要的受害者可能不会先运送。
- 在事后批评期间，将对分诊感到不满。
Who Should Do Triage?
Triage should be simple, easy to use, and easy to learn. EMTs or first responders who are more numerous and arrive at an incident in its early stages should triage. They are also more likely than advanced life support providers to just triage and move on to the next patient. Paramedics and other medical personnel should treat and transport the most critically injured victims.
Keep It Simple
Simple Triage and Rapid Treatment (START) is a rapid primary process that is easy to remember and easy to teach. In 1983, START was developed in Newport Beach, California and was designed to work within the incident command system. The process takes between 30 and 60 seconds per victim. It is based on three simple assessments. No tools, special equipment, or advanced medical knowledge is required. Basic lifesaving measures such as opening airways and controlling external bleeding are performed as needed. Bystanders or the “walking wounded” are used to actually deliver these measures.
您的第一步是指导任何可以步行到指定安全的地方的人。如果他们可以走路，这些受害者可以在其他救援人员到达时对这些受害者进行评估和标记。现在，这会导致较小的分类受伤，您可以开始快速评估。使用助记符“ 30-2-can do”（呼吸少于每分钟30，毛细血管补充少于2秒，受害者可以做您的要求）。如果不存在这三个标准中的任何一个，则受害人是“立即”。当受害者可以走路并满足此标准时，他们被标记为“次要”。当受害者无法行走时，他们被标记为“延迟”。偏离这些标准（无意识，呼吸迅速，毛细血管补充或不存在径向脉冲）表明严重受伤。如果呼吸在打开气道时没有恢复，则受害者被标记为“死亡/太平间”。在多种事件中，没有尝试复苏。 START is used across the United States and internationally. It is successful because of its simplicity and ease of use.
Retriage
在时间和资源允许的情况下，使用传统的体格检查技术进行复发。最初将有受害者三叶草为“延迟”，他们将受到重大伤害。期望和计划。留在事件并接受治疗的受害者可能会有所改善，并将其分类类别降级。
分类文档类别
启动将使用任何分类标签。加利福尼亚消防局长协会认可了一个标签，该标签在上面打印了起点。这使得每次使用一个标签时都可以轻松加强分诊过程。没有完美的分类标签，但是即使很少使用，好的标签也很容易理解。最重要的是，分类标签是一种至关重要的通信和文档工具，需要在一个地区进行标准化，因此所有救援人员和医务人员都熟悉它。优先级类别在标签的底部列出。这些类别是死亡/太平间，直接，延迟和次要的。通常，它们位于标签的底部，也进行了颜色编码以易于使用。
Start and the Incident Command System (ICS)
开始在集成电路设计工作。当届e first units arrive at a multicasualty incident, they are certainly going to be overwhelmed. There is a temptation to set up the management levels for the incident first, so the operational levels will have supervision when they are assigned. To do this, most organizations have to use personnel from the first or second wave of responding resources. This removes them from the triage/transportation/ treatment provider role, creating a delay in getting victims to the hospital. After 10 to 20 minutes, it’s a sad sight to see many rescuers wearing command vests and setting up their operations while no one is attending the victims.
Victims who are seriously ill or critically injured have a narrow time frame known by trauma care professionals as the “Golden Hour,” the optimum limit from time of injury to surgery at a hospital. Medical studies have demonstrated that survival rates are highest when surgical interventions take place within one hour. This is why the emphasis is on rapid triage and transportation rather than building a management structure.
请记住，直到超出控制的最大控制范围，就不必分配中管理位置。事件指挥官应尽可能地将第一派操作单位分配给动手功能。通常，所需的管理功能是命令，分类/治疗，运输和通信。组织这些功能将对您能够分类，运输和治疗患者的速度产生积极影响。这被称为ICS的“自下而上”方法。在运输受害者之前，评估需要做什么，并且很清楚需要在哪里分配初始资源。
Build from the Bottom Up
- 在您可以将受害者送往医院之前，您需要从区域协调员那里提供可用的救护车和医院目的地。
- Before you can get a hospital destination, you need to know what category and how many victims are loaded in an ambulance.
- Before you can identify what triage category the victims are, they must be tagged and carried to the ambulance loading area.
- Before they can be tagged, they must be triaged.
Typical Problems at MCIs
这看起来“r?
- Failure to triage.
- Failure to retriage.
- Slow movement and collection of victims.
- Inappropriate care.
- 运输延迟。
Psychological Considerations
救援人员不受灾难的心理影响。执行分诊的人感觉好像在决定谁立即照顾，谁必须等待以及谁没有得到。分类同事或家人的额外压力大大增加了情感上的伤害。
During the incident, rotating triage teams and treatment teams to other assignments can shorten the exposure and decrease the emotional stress. Critical incident stress professionals should monitor all incident personnel to help reestablish the emotional well-being of the rescuers.
Pediatric Triage
Management of injured children at an MCI is challenging. Injured children tug at our heartstrings and most likely will be triaged by emotion as “immediate.” Even if uninjured, they require supervision and protection. If their caretakers are injured or not available, rescuers must assume this task.
Prioritizing children over more critically injured adults denies resources to those who need them most. One of the reasons START was developed was to provide an objective tool for prioritizing care for victims. Objectivity assists us in doing the most good for the most people.
Until 1995, there was no triage process that specifically addressed the unique anatomy and physiology of children. Dr. Lou Romig, a pediatric emergency physician based in Florida, developed JumpSTART in response to this need. JumpSTART is a tool based on START but adapted to the uniqueness of the pediatric victim. JumpSTART was designed for children who are under the age of eight or who weigh less than 100 pounds.
JumpSTART adaptations include the following:
- 如果孩子不呼吸，则在打开呼吸道后呼吸5。
- A respiratory rate of less than 15 or greater than 45 categorizes the child as immediate.
- Perfusion is determined by checking a distal pulse.
- Mental status is evaluated based on levels of responsiveness as the age and development of the child allow. The assessment prompt AVPU can help you remember what you need to evaluate. The letters stand for alert, verbal stimuli, painful stimuli, and unconscious.
There are variations between START and JumpSTART parameters used to determine a triage category, but the outcome is the same. For instance, alterations in mental status are both classified as “Immediate.” Other differences occur with younger children who are unable to walk, who are unable to obey commands, or who are not breathing but who have a pulse. The apneic child is given 5 rescue breaths and a pulse check before being tagging as deceased. With this simple intervention, a child could be saved.
Triage is the basic tool you need to manage victims at a multicasualty event. It helps rescuers reduce the emotions and stress of a large-scale event and improve efficiency by having an objective tool at the ready.
如果您所在地区没有开始和跳动，我强烈建议您将这些系统引起培训官的注意。要求对它们进行评估以进行实施。
Victoria Cleary is the EMS manager for the Newport Beach (CA) Fire Department. She has been involved in prehospital care since 1975 as a clinician, educator, and manager. She is one of the co-developers of the START triage system.
